The recent National Association of Clinical Nurse Specialist's conference included plenty of chatter about the changes wrought by the Advanced Practice Registered Nursing (APRN) Consensus Model.1 One thing that percolated to the top and persisted throughout the conference was the phrase "from wellness to illness" as the focus of care. Now, graduate curricula, the 500 required hours of clinical experiences, and certification examinations should include wellness and illness. Historically, nurses have helped people stay well, get well, live well. Nurses help people who are ill to get well, yes? Clinical nurse specialist practice includes a focus on wellness and illness, which was made explicit in the first edition of the National Association of Clinical Nurse Specialist (NACNS) Statement on Clinical Nurse Specialist Practice and Education.2 And yet, it's not clear exactly what is being advocated by the purveyors of change.
Wellness and illness are not universally defined terms, or concepts. In common usage, wellness is considered the absence of disease, whereas illness denotes the presence of disease. Within nursing, however, wellness and illness are much more nuanced with specific meaning and usages. Nightingale first noted the difference between the experience suffering and the presence of disease in her oft-quoted statement:
In watching disease... the thing that strikes the experienced observer most forcibly is this, that the symptoms or sufferings generally considered to be inevitable and incident to disease are very often not the symptoms of the disease at all, but of something quite different-of what of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administrations of diet, of each or all of these things.3(p8)
Early nurse theorists-Levine, Wiedenbach, Henderson, to name a few-focused the budding discipline of nursing on conceptualizations involving nursing care aimed at providing comfort and supporting function. In their era, physicians diagnosed and treated the pathological conditions of disease; nurses provided care and comfort. Nursing practice was dependent on and directed by physicians. Beginning in the 1970s, state statutes regulating nursing practice were amended to create an independent scope of practice for nurses. A scope of practice provides a legal protection for independent diagnosis and, most important, the right to act independently on one's judgment relative to the diagnosis. It was the New York Nurses Association that first defined nursing diagnosis, which was picked up by the American Nurses Association in the first Social Policy Statement.4 Nursing diagnosis was defined as "the diagnosis and treatment of human responses to actual and potential health problems."4 Henceforth, independent nursing practice has been focused on the human experience, and correspondingly nursing research has produced large body biobehavioral science as the basis for interventions related to the human experience of health problems.
Health problems in the United States and many Western countries tend to be chronic, underlying, lingering pathologies prone to exacerbations and remissions and requiring anywhere from minimal to complex self-maintained treatment routines. Resulting from her work in home healthcare, Larsen5 noted a more contemporary difference between disease and suffering. Disease is pathology, a change in physical structure and function that can be quantified, measure, and described. Illness is the experience of the patient and family; it is what is lived in the context of cultural, social, and economic worlds and is different from disease. Similarly, illness as lived experience was defined in the second edition of the NACNS Statement on Clinical Nurse Specialist Practice and Education as "the subjective experience of somatic discomfort, including physical discomfort, emotional discomfort, and/or a reduction in functional ability below the perceived capability level."6(p64)
Wellness and illness are not dichotomous states where a person can pick one but not both. Nor is wellness to illness a continuum of, perhaps, very well, sorta well, not so well, maybe ill, kinda ill, very ill. How would placement of such a continuum determined? Could one person's sorta well be another person's kinda ill? Wellness exists in disease as individuals and their families live the experience of striving to function at maximum ability with minimal symptoms and suffering. Many people are functioning with a diagnosed disease-diabetes, asthma, arthritis, hypertension, to name but a few. For the most part, these individuals would say of themselves that they are well because they are functioning to their perceived highest level. Wellness can be experienced in the presence or absence of disease.6
Why is it important to have clarity about wellness and illness? The APRN Consensus Model is working on congruence among education, certification, practice, and regulation. With regard to certification, the NP and CNS Certification Rulemaking Guide posted on the ANA Web site (http://www.nursingworld.org/rulemakingguide, accessed March 13, 2013) states "All Clinical Nurse Specialist educational programs will include content, and certification examinations will test competencies, from wellness through acute care, regardless of population focus." This statement is conceptually awkward because it is not on a consistent conceptual plane-wellness is a lived experience, and acute care is a nursing deliverable. Are wellness and illness care setting dependent-wellness in one kind of setting, maybe outpatient clinics, and illness in another setting like a hospital? If I may offer a clarification, the amended statement would read: "[horizontal ellipsis]educational programs will include content, and certification examinations will test competencies of wellness in illness with emphasis on maximizing function, promoting comfort and relieving suffering in the lived experience of patients and their families across disease conditions inclusive of prevention, acute and chronic."
Beyond the practical need for clarity, unambiguous definitions are foundational to keeping our professional social contract to contribute to the public good. Wellness in illness directs nursing practice to include interventions for achieving self-care outcomes, that is, assisting patients and families to live their best lives in the presence of disease. Nursing practice incorporates knowledge of disease and its treatment with biobehavioral science and applies this knowledge to the context of individual lives for the purpose of achieving wellness in illness. This desired outcome crosses the continuum of care settings from primary care, acute care, home care, and rehabilitation and long-term care.
Physicians will continue to serve as society's master diagnosticians using an ever-expanding battery of technology to achieve exactness and to likewise treat disease with surgical and pharmacological precision. Diagnosis of simple, common pathologies is becoming the responsibility of other licensed care providers, including advanced practice nurses. Our professional history and ongoing commitment to wellness in illness provide the way forward for the future of nursing in a redesigned healthcare world. Clinical nurse specialist practice has been focused on interventions for patients and families for the purpose of maintaining the highest possible level of wellness in the experience of living with a disease regardless of the disease, treatment, or care setting. Clarity related to changes wrought by the APRN Consensus Model may well be in order, but wellness in illness was long ago established in nursing practice, and it applies to all specialties and care settings.
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